PRE-TRAVEL HEALTH & VACCINATION ASSESSMENT

Hoy & Walls Health Centre

Surname ______

Forename ______

Telephone ______

Date of Birth ______

M/F ______

1. What is your departure date ?

______

2. How long will you be away ?

______

3. Which countries do you intend to visit ?

(including brief stopovers)

______

______

______

4. Will your journey take you to the:-

  • coast ?
  • interior ?
  • islands ?

5. Will you be staying in:-

  • tourist hotels ?
  • relatives’ homes ?
  • local accommodation ?

6. Are you travelling with:-

  • family ?
  • partner ?
  • alone ?
  • group ?

7. Are you going on:-

  • an organised package tour ?
  • organising it yourself ?
  • taking a backpacking holiday ?

8. Is your holiday for:-

  • pleasure ?
  • business ?
  • for a period of voluntary service

in a remote area ?

9. Will you be going on safari, travelling in

areas with poor communication or

participating in adventure sports ?

Yes No (If yes, please give details)

______

______

10. Will you be in areas where medical help is

non-existent (even for a short period) ?

Yes No (If yes, please give details)

______

______

11. Are you suffering from any minor ailments ?

Yes No (If yes, please give details)

______

______

12. Do you have any long-term medical

conditions ?

Yes No (If yes, please give details)

______

______

13. Do you have a history of epilepsy ?

Yes No (If yes, please give details)

______

______

14. Have you ever experienced anxiety,

depression or other psychological problems

which have required treatment ?

Yes No (If yes, please give details)

______

15. Have you had your spleen removed ?

Yes No (If yes, please give details)

______

16. Have you ever had a bad reaction to a

vaccine ?

Yes No (If yes, please give details)

______

17. Do you have any other allergies, e.g. eggs ?

Yes No (If yes, please give details)

______

18. Are you taking any medication including

the oral contraceptive pill, or have you been

on antibiotics within the last 10 days ?

Yes No (If yes, please give details)

______

19. Are you pregnant, breast-feeding or

planning a pregnancy ?

Yes No (If yes, please give details)

______

20. Are you HIV positive ?

Yes No (If yes, please give details)

______

21. Have you recently received treatment with

radiotherapy, chemotherapy or steroids ?

Yes No (If yes, please give details)

______

22. Are any children who are travelling up to

date with their childhood vaccinations ?

Yes No (If no, please give details)

______

23. Have you previously had any vaccinations ?

Yes No

______

24. Have you had any of the following

vaccinations and, if so, when ?

Typhoid Meningitis

Tetanus Rabies

Polio Japanese Encephalitis

Yellow Fever Tick-borne Encephalitis

Hepatitis A Diphtheria

Hepatitis B

______

Hoy & Walls Health Centre

Vaccines Required / Vaccines Given
1.
2.
3.
4.

Malaria Prophylaxis: Yes No
Product:…………………………………………

Hoy & Walls Health Centre

Hoy & Walls Health Centre